Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Father Baker Manor during CMS and state inspections, most recent first.
A resident with Parkinson’s disease, dementia, and anxiety received another resident’s potent medications, including opioids and other CNS-acting drugs, after an LPN pre-poured medications for about 20 residents and misidentified a pill, administering the wrong medication cup. Facility policy required correct resident identification and adherence to the six rights of medication administration, but the LPN’s pre-pouring and misadministration led to the resident receiving an incorrect regimen. Subsequent documentation showed hypotension, bradycardia, lethargy, and decreased respirations, with limited and delayed physician notification and incomplete nursing documentation of the resident’s changing condition, culminating in the need for Narcan as ordered by the physician.
A facility failed to report an allegation of abuse within the required timeframe when a CNA reported to an RN that another CNA had slapped a resident with dementia and severe cognitive impairment. The RN did not escalate the report to a supervisor or administration, resulting in a four-day delay before the incident was reported to the DON and Administrator, contrary to policy and state regulations.
A facility failed to promptly investigate an allegation of physical abuse involving a resident with dementia and severe cognitive impairment. The accused CNA continued working after the allegation, and the investigation was delayed, lacking timely staff statements, assessment of the resident for injuries, and interviews or assessments of other residents cared for by the accused. Key investigative steps required by facility policy were not followed.
A resident with Parkinson's disease and mobility issues was injured during a transfer when a CNA failed to use a gait belt as required by the care plan. The resident sustained skin tears after being transferred hurriedly without the gait belt, leading to a fall against their wheelchair. Interviews confirmed the CNA's failure to follow the care plan, which mandated the use of a gait belt for safe transfers.
A nurse failed to follow enhanced barrier precautions by not wearing a gown while caring for a resident with a feeding tube, despite the presence of setup instructions. The resident had multiple health issues requiring tube feeding, and the facility's policies did not adequately address the necessary precautions. Interviews with staff confirmed the expectation to wear protective equipment, highlighting a deficiency in infection control practices.
Significant Medication Error from Pre-Poured and Misadministered Drugs
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when an LPN pre-poured and misadministered medications. Facility policy on medication administration required staff to identify the resident, compare the medication label to the medication administration record, prepare and administer ordered medications to the correct resident, and document administration. Despite this, on the evening of 02/23/2026, LPN #1 pre-poured medications for approximately 20 residents for the entire shift into plastic cups labeled with resident names, contrary to expectations not to pre-pour. During administration, LPN #1 misidentified pregabalin, believing it matched a medication ordered for Resident #1, and administered a full cup of medications intended for Resident #2 to Resident #1. Resident #1 had diagnoses including Parkinson’s disease, dementia, and anxiety, and received multiple psychotropic and anticoagulant medications as part of their usual regimen. The resident’s care plan directed staff to administer medications per provider orders and monitor for adverse reactions and effectiveness. After the wrong medications were given, documentation by LPN #1 at 9:09 PM on 02/23/2026 noted that another resident’s medications had been administered and that the nursing supervisor, physician, and family were notified, with vital signs reportedly stable at that time. However, the Weights and Vitals Summary at 12:05 AM on 02/24/2026 showed a blood pressure of 90/52 and heart rate of 52, with no corresponding nursing notes or additional vital signs documenting assessment of these changes or any change in mental status, and there was no documented evidence that the physician was notified of these findings. Subsequently, in the early morning hours of 02/24/2026, LPN #2 documented that Resident #1 was difficult to arouse, responded minimally to sternal rub, had a blood pressure of 85/50, and had extended periods between respirations. A follow-up note recorded that only a level 3 voicemail (non-urgent, no return call necessary) was left for the physician. RN Supervisor #2 documented the resident was lethargic but responsive to verbal and tactile stimuli, with blood pressure 85/50, pulse 50, and respirations 10 with pauses between breaths followed by heavy breaths. When the physician evaluated the resident later that morning for an acute visit related to the medication error, the resident was sleeping, not following commands, and had a respiratory rate of 10; Narcan was ordered and administered. Interviews with the pharmacy consultant, DON, attending physician, and medical director confirmed that nurses were expected to follow the six rights of medication administration and not pre-pour medications, and that the medications erroneously given were potent agents capable of causing lethargy, decreased blood pressure, decreased respirations, and altered mental status.
Delayed Reporting of Alleged Abuse Incident
Penalty
Summary
A deficiency occurred when the facility failed to ensure that an allegation of abuse was reported immediately, but not later than two hours after the allegation was made, as required by facility policy and state regulations. Specifically, a Certified Nurse Aide reported to a Registered Nurse that they witnessed another aide slap a resident across the face in the shower room. The Registered Nurse did not report this allegation to the supervisor or administration, stating they became busy and had no other excuse. As a result, the incident was not reported to the Administrator or the New York State Department of Health until four days later, when the aide who witnessed the event reported it to the unit manager, who then informed the Administrator. The resident involved had diagnoses including dementia, anxiety, and type 2 diabetes, with severe cognitive impairment and required substantial assistance with bathing. At the time of observation, the resident was alert only to self and showed no visible injuries. Interviews with staff confirmed that the required reporting process was not followed, with both the Registered Nurse and supervisor acknowledging that the incident should have been reported immediately according to policy. The delay in reporting resulted in non-compliance with the facility's abuse reporting requirements.
Failure to Immediately Investigate and Prevent Further Potential Abuse Following Allegation
Penalty
Summary
A deficiency occurred when the facility failed to respond appropriately to an allegation of physical abuse involving a resident with severe cognitive impairment, dementia, anxiety, and type 2 diabetes. The incident involved a staff member allegedly witnessing another staff member slap the resident during a shower. Despite the facility's policy requiring immediate initiation of an investigation and interventions to prevent further abuse, there was a delay in starting the investigation, and the accused staff member continued to work subsequent shifts after the allegation was made. The investigation file lacked evidence that it was initiated immediately upon the report of abuse. Written statements from staff were dated several days after the incident, and there was no documentation that the accused staff member was contacted for a statement. Additionally, there was no evidence that other residents cared for by the accused were assessed or interviewed to determine if there were additional victims. Progress notes for the days following the incident did not document any assessment of the resident for injuries until several days later, when a nurse practitioner noted no injuries. Interviews with staff revealed that the initial report of abuse was made to a registered nurse, who did not document an assessment or initiate an incident report. The accused staff member was not immediately removed from resident care and continued working until terminated for an unrelated reason. The Director of Nursing and Administrator confirmed that the investigation was not started until days after the incident and that key investigative steps, such as interviewing the accused and assessing other potentially affected residents, were not completed. The facility's failure to follow its own abuse investigation policy resulted in a lack of timely and thorough investigation and did not prevent further potential abuse or mistreatment while the investigation was in progress.
Failure to Use Gait Belt During Transfer Results in Resident Injury
Penalty
Summary
The facility failed to ensure adequate supervision and use of assistive devices to prevent accidents for a resident with Parkinson's disease, muscle weakness, and difficulty in walking. The resident, who was cognitively intact, required touching or steadying assistance for transfers to the toilet as per their care plan. The care plan specified the use of a gait belt and a grab bar for safe transfers. However, during a transfer, a Certified Nurse Aide (CNA) did not utilize the gait belt, resulting in the resident sustaining skin tears to their left forearm. The incident occurred when the CNA transferred the resident using only the grab bar, without consulting the care plan. The resident reported being transferred hurriedly, which led to them falling against their wheelchair and receiving injuries. Interviews with the resident, the Registered Nurse Unit Nurse Manager, the Director of Social Work, and the Director of Nursing confirmed that the CNA did not follow the care plan, which required the use of a gait belt for transfers. The CNA admitted to not using the gait belt and acknowledged the oversight in ensuring resident safety.
Inadequate Infection Control Practices for Resident with Feeding Tube
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the actions of a nurse who did not adhere to enhanced barrier precautions during the care of a resident with a feeding tube. The Centers for Medicare and Medicaid Services Quality Safety and Oversight memoranda indicated that enhanced barrier precautions, including the use of gowns and gloves, were necessary for residents with indwelling medical devices, such as feeding tubes, to prevent the transmission of multidrug-resistant organisms. However, the facility's policies did not adequately address these precautions, and during an observation, a nurse was seen not wearing a gown while performing a bolus feed for a resident on enhanced barrier precautions. The resident involved had multiple diagnoses, including dysphagia, gastroesophageal reflux disease, and congestive heart failure, and required tube feeding due to swallowing difficulties. Despite the presence of enhanced barrier precautions setup outside the resident's room, the nurse only wore gloves and not a gown, resulting in potential cross-contamination. Interviews with the nursing staff, including the LPN involved, the RN Unit Nurse Manager, the Assistant Director of Nursing Infection Preventionist, and the Director of Nursing, revealed a lack of adherence to expected protocols for wearing personal protective equipment during care of residents on enhanced barrier precautions.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 146 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Orchard Park
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Fox Run At Orchard Park | 2.3 mi | ★★★★★ | 0 | 0 |
| Elderwood At Hamburg | 4 mi | ★★★★★ | 3 | 0 |
| Autumn View Health Care Facility L L C | 4.2 mi | ★★★★★ | 3 | 0 |
| Absolut Center For Nursing And Rehabilitation At A | 6.9 mi | ★★★★★ | 0 | 0 |
| Mercy Hospital Skilled Nursing Facility | 7.4 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Father Baker Manor.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.